Determinants of Healthcare Utilisation and Out-of-Pocket Payments in the Context of Free Public Primary Healthcare in Zambia

Document Type : Original Article


Department of Economics, University of Zambia, Lusaka, Zambia


Access to appropriate and affordable healthcare is needed to achieve better health outcomes in Africa. However, access to healthcare remains low, especially among the poor. In Zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. The paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (OOP) payments related to a visit to a health provider.
This paper employs a multilevel multinomial logistic regression to model the determinants of an individual’s choice of healthcare options following an illness. Further, the study analyses the drivers of the magnitude of OOP expenditure related to a visit to a health provider using a two-part generalised linear model. The analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014.
Household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [OR] = 1.12, P = .000). Living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (OR = 1.54, P = .000) and (OR = 1.55, P = .01), for secondary and tertiary education, respectively. Rural residence is associated with reduced odds of seeking formal care (OR = 0.706, P = .002). The magnitude of OOP expenditure during a visit is significantly dependent on household economic wellbeing, distance from a health facility, among other factors. A 10% increase in per capita consumption expenditure was associated with a 0.2% increase in OOP health expenditure while every kilometre travelled was associated with a K0.51 increase in OOP health expenditure.
Despite the removal of user fees on public primary healthcare in Zambia, access to healthcare is highly dependent on an individual’s socio-economic status, illness type and region of residence. These findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in Zambia and other countries in sub-Saharan Africa.


Main Subjects

  1. World Health Organisation (WHO). Health systems financing: the path to universal coverage. World Health Report. Geneva: WHO; 2010
  2. Institute for Health Metrics and Evaluation, Human Development Network, The World Bank.  The Global Burden of Disease: Generating Evidence, Guiding Policy: Sub-Saharan Africa Regional Edition. Seattle, WA: IHME; 2013
  3. Gwatkin DR. How well do health programmes reach the poor? Lancet. 2003;361:540-541. doi:10.1016/S0140-6736(03)12558-5
  4. Gilson L. The lessons of user fee experience in Africa. Health Policy Plan. 1997;12:273-285. doi:10.1093/oxfordjournals.heapol.a018882               
  5. Xu K, Evans DB,  Kadama P, et al. Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda. Soc Sci Med. 2006;62:866-876. doi:10.1016/j.socscimed.2005.07.004
  6. Mwabu G, Mwanzia J,  Liambila W. User charges in government health facilities in Kenya: Effect on attendance and revenue. Health Policy Plan. 1995;10:164-170. doi:10.1093/heapol/10.2.164
  7. Lagarde M, Palmer N. The impact of user fees on health service utilization in low- and middle-income countries: How strong is the evidence. Bull World Health Organ. 2008;86(11):839-848.  doi:10.2471/BLT.07.049197
  8. Chenge MF, Van der Vennet  J,  Luboya NO,  Vanlerberghe V, Mapatano MA, Criel B. Health-seeking behaviour in the city of Lubumbashi, Democratic Republic of the Congo: Results from a cross-sectional household survey. BMC Health Serv Res. 2014;14:173. doi:10.1186/1472-6963-14-173
  9. Nabyonga-Orem  JN, Mugisha F, Kirunga C,  Macq J,  Criel  B. Abolition of user fees: The Uganda paradox. Health Policy Plan. 2011;26:ii41-ii51. doi:10.1093/heapol/czr065
  10. Laokri S, Weil O, Drabo MK, Dembelé MS,  Kafando B, Dujardin B.  Removal of user fees no guarantee of universal health coverage: Observations from Burkina Faso. Bull World Health Organ. 2013;91:277-282. doi:10.2471/BLT.12.110015
  11. Ministry of Health (Zambia). National Health Strategic Plan 2011-2015. Lusaka: Ministry of Health; 2011.
  12. Masiye F, Chitah BM, McIntyre D. From targeted exemptions to user fee abolition: Experience from rural Zambia. Soc Sci  Med. 2010;71:735-750. doi:10.1016/j.socscimed.2010.04.029
  13. Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan. 2011;26:1-11.
  14. McLaren ZM,  Ardington C, Leibbrandt M. Distance decay and persistent health care disparities in South Africa. BMC Health Serv Res. 2014;14:541. doi:10.1186/s12913-014-0541-1
  15. Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004;19:69-79. doi:10.1093/heapol/czh009
  16. Central Statistics Office. Living Conditions Monitoring Survey Report 1996. Lusaka: Central Statistics Office, Zambia; 1998.
  17. Central Statistics Office. Living Conditions Monitoring Survey Report 2002/3. Lusaka: Central Statistics Office, Zambia; 2003.
  18. Central Statistics Office. Living Conditions Monitoring Survey Report 2006. Lusaka: Central Statistics Office, Zambia; 2007.
  19. Central Statistics Office. Living Conditions Monitoring Survey Report 2010. Lusaka: Central Statistics Office, Zambia; 2012.
  20. Central Board of Health. Health Planning Guide. Lusaka: Central Board of Health, Infrastructure Unit, Zambia; 2002.
  21. Grossman M. On the concept of health capital and the demand for health. J Polit Econ. 1972;80:223-255. doi:10.1086/259880
  22. Muurinen JM. Demand for health: a generalised Grossman model. J Health Econ. 1982;1:5-28. doi:10.1016/0167-6296(82)90019-4
  23. Wagstaff A. The demand for health: some new empirical evidence. J Health Econ. 1986;5(3):195-233
  24. Kenkel DS. The demand for preventive medical care. Appl Econ. 1994;26(4):313-325.
  25. Sauerborn R, Nougtara A,  Latimer E. The elasticity of demand for health care in  Burkina Faso: differences across age and income groups. Health Policy Plan. 1994;9(2):185-192.
  26. Meyer B, Sullivan J. Measuring the well-being of the poor using income and consumption.  J Hum Resour. 2003;38:S1180-S1220. doi:10.2307/3558985
  27. Uzochukwu BS,  Onwujekwe OE. Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: A case study of four local government areas operating the Bamako initiative programme in south-east Nigeria. Int J Equity Health. 2004;3:6. doi:10.1186/1475-9276-3-6
  28. Wagstaff A.  The demand for health: Some new empirical evidence. J Health Econ. 1986;5(3):195-233. doi:10.1016/0167-6296(86)90015-9
  29. Windmeijer FA, Santos Silva JM. Endogeneity in count data models: an application to the demand for health care. J Appl Econ. 1997;12:281-294. doi:10.1002/(SICI)1099-1255(199705)12:3%3C281::AID-JAE436%3E3.0.CO;2-1
  30. Pohlmeier W, Ulrich V. An econometric model of the two-part decisionmaking process in the demand for health care. J Hum Resour. 1995;30:339-361. doi:10.2307/146123
  31. Sauerborn R, Nougtara A, Latimer E. The elasticity of demand for health care in Burkina Faso: Differences across age and income groups. Health Policy Plan. 1994;9:185-192. doi:10.1093/heapol/9.2.185
  32. Diez Roux AV. Investigating neighbourhood and area effects on health. Am J Public Health. 2001;91:1783-1789. doi:10.2105/AJPH.91.11.1783
  33. Bingenheimer  JB, Raudenbush SW. Statistical and substantive inferences in public health: Issues in the application of multilevel models. Annu Rev Public Health. 2004;25:53-77. doi:10.1146/annurev.publhealth.25.050503.153925
  34. Pickett KE, Pearl M. Multilevel analyses of neighbourhood socioeconomic context and health outcomes: A critical review. J Epidemiol Community Health. 2001;55:111-122. doi:10.1136/jech.55.2.111
  35. Jones AM,  Culyer AJ,  Newhouse JP. Handbook of Health Economics.  Amsterdam: North-Holland; 2000.
  36. Mihaylova B, Briggs A, O'Hagan A, Thompson SG. Review of statistical methods for analysing healthcare resources and costs. Health Econ. 2011;20:897-916. doi:10.1002/hec.1653
  37. Liu L, Strawderman  RL, Cowen ME, Shih YCT. A flexible two-part random effects two-part model for correlated medical costs. J Health Econ. 2010;29:110-123. doi:10.1016/j.jhealeco.2009.11.010
  38. Leung  SF, Yu S. On the choice between sample selection and two-part models. J Econ.. 1996;72:197-229. doi:10.1016/0304-4076(94)01720-4
  39. Belotti F, Deb P, Manning WG, Norton EC. tpm: Estimating Two-part Models. fter nt13.2 Willingness to pay  e bar chart below primary health care: theStata J 2012;15(1):3-20.
  40. Manning WG,  Mullahy J. Estimating log models: To transform or not to transform? J Health Econ. 2001;20:461-494. doi:10.1016/S0167-6296(01)00086-8
  41. Mullahy J. Much ado about two: reconsidering retransformation and the two-part model in health econometrics. J Health Econ. 1998;17:247-281. doi:10.1016/S0167-6296(98)00030-7
  42. Hjortsberg  C. Why do the sick not utilise health care? The case of  Zambia. Health    Econ. 2003;12:755-770. doi:10.1002/hec.839
  43. Mbagaya GM,  Odhiambo MO,  Oniang’o RK. Mother’s health seeking behaviour during child illness in a rural western Kenya community. Afr Health Sci. 2005;5:322-327.
  44. esqualityponses to reducing ctors described above average OOPPs as a percentage of income is 40 percent.,ncial burdents more frOrem JN, Mugisha F, Okui AP, Musango L, Kirigia JM. Health care seeking patterns and determinants of out-of-pocket expenditure for Malaria for the children under-five in Uganda. Malar J 2013;12:1-11. doi:10.1186/1475-2875-12-175
  45. Ridde V, Haddad S, Heinmüller R.  Improving equity by removing healthcare fees for children in Burkina Faso. J Epidemiol Community Health. 2013.67:751-757.   doi:10.1136/jech-2012-202080
  46. Wang Q, Fu AZ, Brenner S, Kalmus O, Banda HT, De Allegri M. Out-of-Pocket Expenditure on Chronic Non-Communicable Diseases in Sub-Saharan Africa: The Case of Rural Malawi. PLoS One. 2015;10(1):e0116897. doi:10.1371/journal.pone.0116897
  47. Buor D. Analysing the primacy of distance in the utilization of health services in Ahafo-Ano South district, Ghana. Int J Health Plann Manage. 2003;18:293-311. doi:10.1002/hpm.729